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Editorial comment

Editorial comment F. Maisano et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 118—123 123 in an animal model. There have been other minimally invasive attempts at that this is a first phase, but do you think that in the future if this happens to be implantation of chordae for repair of the mitral valve, including mini- clinically available it should be complemented with some ring device or with thoracotomy and robotic assistance. However, with these techniques, some coronary sinus device in order to stabilize results in the longer term? cardiopulmonary bypass and arrest of the heart is needed. Measurement of Dr Maisano: I think there is no doubt about this. Obviously mitral annular the chordae and its assessment can be difficult in an arrested heart. Maisano enlargement happens, although later in the course of the disease. So you may and colleagues have overcome these difficulties in their model, making imagine that if you treat patients earlier, you may be able to avoid measurement of the chordae easier. I have two questions for you. annuloplasty. But I don’t think there will be any problem in the future to You have used midline sternotomy. Why did you use this as opposed to a approach these patients with a more broad spectrum of devices, and with mini-anterolateral thoracotomy to reach the apex? My second question: is associated procedures. Unfortunately there are some regulatory issues which blood loss a problem in your model? I look forward to the demonstration of this will make this solution unavailable in the next few years, but in the long term, technique under pathological conditions. there will probably be a solution like this. Dr Maisano: Midline sternotomy is needed in the pig model because of the Dr G. Lutter (Kiel, Germany): You have told us about the difficulties, on rotation of the heart, and if you would transfer this procedure to the human the one hand visualization, and on the other hand, an available ischemic mitral setting, this would be done under regular transapical access in the fifth or sixth regurgitation model. I believe the Gorman brothers’ work in Philadelphia could intercostal space in a left thoracotomy in the mid subclavian line. connect nicely to yours. A nice ischemic model with induced myocardial infarction and a resulting moderate-severe degree of mitral regurgitation to Answering the question of the lack of a pathological model, I have been perform your experiments in this sheep model would be very interesting. working on several of these devices, and obviously this would be very useful to prove not only the concept but also the feasibility of the procedure itself. Dr Maisano: Unfortunately, I don’t think this chordal replacement is going Unfortunately, this model is not available, and it is very difficult to obtain on most to be directed to ischemic patients. So what is lacking is a degenerative mitral occasions. You may obtain a chordal rupture model, but this is still not a viable regurgitation model, which can be done but is not really reproducing what we model for mitral valve prolapse, because then you will have only the chordal see in the patients today we operate on. Obviously if you imagine the evolution rupture but not the degeneration of the tissue in the area of the chordal rupture. of these technologies in the future and an earlier implant of these devices or an earlier application of these procedures, that might be a new disease to tackle. These are the obvious limitations of this model, but the aim of the study So we need to be prepared for many other experiments in the future. But thank was to demonstrate the feasibility of a minimally invasive off-pump chordal you for your suggestion. implantation with real-time sizing on neochordae. Dr Lutter: But this technology might at least be used in primary and Blood loss was not an issue in this experience since leaflet capture was secondary MR, to varying degrees, as you told us. Is this correct? quite straightforward, keeping blood loss to a minimum. Dr Maisano: Sure. Dr F. Casselman (Aalst, Belgium): All clinical studies on degenerative mitral valve repair show inferior results if no ring is placed. Now, I understand [h1]I forgot to answer to this question, if the editor wants to include this.. . Keywords: Mitral valve repair; Neochordae; Prolapse; PTFE This paper [1] on experimental transapical chordal anchoring of the neochords at both papillary muscles, which implantation describes an innovative approach for future is a relative constant distance even when left ventricular mitral valve repair for patients with mitral valve prolapse. dilatation occurs. The transapical chord insertion technique The idea for this approach is quite unique and may have been would allow for precise chordal length adjustment under influenced by recent clinical experiences in transapical aortic echocardiographic control. Long-term studies will also need valve implantation. The straight access and short distance to be performed to determine if re-remodeling of the dilated from the apex to the mitral valve seemed to be advantageous left ventricle will result in transapical neochords that are too when applied to the Mobius catheter system. This same group long, and subsequent recurrent mitral regurgitation. of investigators has tried to use the same Mobius system for transfemoral ‘edge to edge MV repair’ without convincing Reference clinical success. The current large animal experimental results are very encouraging for two reasons: first, the [1] Maisano F, Michev I, Rowe S, Addis A, Campagnol M, Guidotti A, Colombo technical challenge seemed to be less than that encountered A, Alfieri O. Transapical endovascular implantation of neochordae using a through a transfemoral approach and second, chordal suction and suture device. Eur J Cardiothorac Surg 2009;36:118—23. replacement represents a standard and long lasting repair Friedrich Wilhelm Mohr technique for mitral valve prolapse. Heart Center, Leipzig University, Struempelstrasse 39, It should be pointed out, however, that the current Mobius 04289 Leipzig, Germany system provides a Prolene suture instead of a PTFE suture, Corresponding author. Tel.: +49 341 8651421; which is the current gold standard for surgical neochordae fax: +49 341 8651452 construction. The authors are aware of this drawback which requires a change before clinical application can be E-mail address: mohrf@medizin.uni-leipzig.de implemented. The transmural PTFE chordal insertion has been previously Available online 9 May 2009 proposed from investigators from the Mayo clinic. First clinical results for this device, however, are still pending. The doi:10.1016/j.ejcts.2009.03.011 current surgical technique for chordal replacement favors an http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Publisher
Oxford University Press
Copyright
© 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
Subject
Original Articles
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1016/j.ejcts.2009.03.011
Publisher site
See Article on Publisher Site

Abstract

F. Maisano et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 118—123 123 in an animal model. There have been other minimally invasive attempts at that this is a first phase, but do you think that in the future if this happens to be implantation of chordae for repair of the mitral valve, including mini- clinically available it should be complemented with some ring device or with thoracotomy and robotic assistance. However, with these techniques, some coronary sinus device in order to stabilize results in the longer term? cardiopulmonary bypass and arrest of the heart is needed. Measurement of Dr Maisano: I think there is no doubt about this. Obviously mitral annular the chordae and its assessment can be difficult in an arrested heart. Maisano enlargement happens, although later in the course of the disease. So you may and colleagues have overcome these difficulties in their model, making imagine that if you treat patients earlier, you may be able to avoid measurement of the chordae easier. I have two questions for you. annuloplasty. But I don’t think there will be any problem in the future to You have used midline sternotomy. Why did you use this as opposed to a approach these patients with a more broad spectrum of devices, and with mini-anterolateral thoracotomy to reach the apex? My second question: is associated procedures. Unfortunately there are some regulatory issues which blood loss a problem in your model? I look forward to the demonstration of this will make this solution unavailable in the next few years, but in the long term, technique under pathological conditions. there will probably be a solution like this. Dr Maisano: Midline sternotomy is needed in the pig model because of the Dr G. Lutter (Kiel, Germany): You have told us about the difficulties, on rotation of the heart, and if you would transfer this procedure to the human the one hand visualization, and on the other hand, an available ischemic mitral setting, this would be done under regular transapical access in the fifth or sixth regurgitation model. I believe the Gorman brothers’ work in Philadelphia could intercostal space in a left thoracotomy in the mid subclavian line. connect nicely to yours. A nice ischemic model with induced myocardial infarction and a resulting moderate-severe degree of mitral regurgitation to Answering the question of the lack of a pathological model, I have been perform your experiments in this sheep model would be very interesting. working on several of these devices, and obviously this would be very useful to prove not only the concept but also the feasibility of the procedure itself. Dr Maisano: Unfortunately, I don’t think this chordal replacement is going Unfortunately, this model is not available, and it is very difficult to obtain on most to be directed to ischemic patients. So what is lacking is a degenerative mitral occasions. You may obtain a chordal rupture model, but this is still not a viable regurgitation model, which can be done but is not really reproducing what we model for mitral valve prolapse, because then you will have only the chordal see in the patients today we operate on. Obviously if you imagine the evolution rupture but not the degeneration of the tissue in the area of the chordal rupture. of these technologies in the future and an earlier implant of these devices or an earlier application of these procedures, that might be a new disease to tackle. These are the obvious limitations of this model, but the aim of the study So we need to be prepared for many other experiments in the future. But thank was to demonstrate the feasibility of a minimally invasive off-pump chordal you for your suggestion. implantation with real-time sizing on neochordae. Dr Lutter: But this technology might at least be used in primary and Blood loss was not an issue in this experience since leaflet capture was secondary MR, to varying degrees, as you told us. Is this correct? quite straightforward, keeping blood loss to a minimum. Dr Maisano: Sure. Dr F. Casselman (Aalst, Belgium): All clinical studies on degenerative mitral valve repair show inferior results if no ring is placed. Now, I understand [h1]I forgot to answer to this question, if the editor wants to include this.. . Keywords: Mitral valve repair; Neochordae; Prolapse; PTFE This paper [1] on experimental transapical chordal anchoring of the neochords at both papillary muscles, which implantation describes an innovative approach for future is a relative constant distance even when left ventricular mitral valve repair for patients with mitral valve prolapse. dilatation occurs. The transapical chord insertion technique The idea for this approach is quite unique and may have been would allow for precise chordal length adjustment under influenced by recent clinical experiences in transapical aortic echocardiographic control. Long-term studies will also need valve implantation. The straight access and short distance to be performed to determine if re-remodeling of the dilated from the apex to the mitral valve seemed to be advantageous left ventricle will result in transapical neochords that are too when applied to the Mobius catheter system. This same group long, and subsequent recurrent mitral regurgitation. of investigators has tried to use the same Mobius system for transfemoral ‘edge to edge MV repair’ without convincing Reference clinical success. The current large animal experimental results are very encouraging for two reasons: first, the [1] Maisano F, Michev I, Rowe S, Addis A, Campagnol M, Guidotti A, Colombo technical challenge seemed to be less than that encountered A, Alfieri O. Transapical endovascular implantation of neochordae using a through a transfemoral approach and second, chordal suction and suture device. Eur J Cardiothorac Surg 2009;36:118—23. replacement represents a standard and long lasting repair Friedrich Wilhelm Mohr technique for mitral valve prolapse. Heart Center, Leipzig University, Struempelstrasse 39, It should be pointed out, however, that the current Mobius 04289 Leipzig, Germany system provides a Prolene suture instead of a PTFE suture, Corresponding author. Tel.: +49 341 8651421; which is the current gold standard for surgical neochordae fax: +49 341 8651452 construction. The authors are aware of this drawback which requires a change before clinical application can be E-mail address: mohrf@medizin.uni-leipzig.de implemented. The transmural PTFE chordal insertion has been previously Available online 9 May 2009 proposed from investigators from the Mayo clinic. First clinical results for this device, however, are still pending. The doi:10.1016/j.ejcts.2009.03.011 current surgical technique for chordal replacement favors an

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Jul 1, 2009

Keywords: Keywords Mitral valve repair Neochordae Prolapse PTFE

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